Pleasant View Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Metter, Georgia.
- Location
- 475 Washington Street, Metter, Georgia 30439
- CMS Provider Number
- 115411
- Inspections on file
- 21
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Pleasant View Nursing Center during CMS and state inspections, most recent first.
The facility did not conduct complete investigations into multiple abuse allegations, including failing to interview involved residents and witnesses as required by policy. In several cases, such as when a resident reported being hit, another alleged inappropriate physical contact, and a hospital social worker raised concerns about bruising, the facility did not document or perform thorough investigations. The Administrator confirmed these investigative steps were missed.
A resident was found to have bruising by a hospital Social Worker, who notified the facility's DON. The DON explained the bruising as resulting from a fall out of a wheelchair, but the facility did not notify the SSA of the physical abuse allegation as required by policy. The Administrator confirmed the incident was not reported.
The facility failed to maintain sanitary conditions for three garbage dumpsters, leading to trash spilling onto the ground and exposure of fecal matter. The issue arose due to nonpayment of the trash service bill, resulting in missed trash pickups. The Maintenance Director informed the Administrator, but no specific instructions were given to address the situation. The Administrator was unaware of the extent of the issue and believed the payment problem had been resolved.
The facility failed to maintain safe water temperatures in resident bathrooms and shower rooms, with temperatures exceeding recommended levels, posing risks of burns and scalds. Additionally, a shower room contained environmental hazards, including a plugged-in hair dryer and unsecured isopropyl alcohol, creating potential accident risks. The facility's policies on water safety and environmental hazards were not effectively implemented, leading to these deficiencies.
A medication cart was found unlocked and unattended on two occasions, contrary to the facility's policy requiring carts to be locked unless under a nurse's supervision. Staff interviews confirmed the oversight, with one nurse attributing the lapse to being distracted by an emergency situation.
The facility failed to follow infection control practices during a glucometer check, with an LPN not using a barrier for supplies. Additionally, washbasins and urinals were improperly stored, and linen handling policies were not followed, leading to potential cross-contamination. Sharps containers were overfilled, posing biohazard risks.
A resident's urinary catheter drainage bag was not covered with a privacy bag, compromising their dignity. Observations showed the bag was uncovered as the resident walked in the hallway. Interviews with the DON, CNA, and Administrator confirmed the need for coverage, but no policy was provided.
Two residents were found with unauthorized medications at their bedsides, including an albuterol inhaler and alcohol-containing mouthwash, despite not being assessed or approved for self-administration. The facility staff were unaware of these medications, indicating a lapse in monitoring.
The facility failed to conduct pre-employment screenings, including reference checks and fingerprinting, for four employees. The Director of Human Resources cited being busy as the reason for not completing these checks, while the Administrator was unaware of the oversight. This deficiency posed a potential risk to residents.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident with dementia did not have a fall mat as required, while two residents with respiratory conditions received incorrect oxygen flow rates. Staff interviews revealed a lack of adherence to care plans.
The facility failed to follow physician's orders for two residents, resulting in deficiencies in care. One resident did not receive ordered therapy evaluations for a hand contracture, while another resident's gastrostomy tube water flushes were not documented as required. Staff interviews confirmed the lapses in following and documenting physician orders.
A resident with a contracture of the left hand did not receive necessary ROM services due to a lack of therapy evaluations and specific care instructions. Despite physician orders for therapy evaluations, the care plan did not include ROM exercises, and the contracture was not noted in the CNA Plan of Care. Observations and staff interviews confirmed the absence of ROM exercises, and the resident was not using a splint device.
Two residents receiving oxygen therapy were administered oxygen at 2.5 LPM instead of the prescribed 2.0 LPM, potentially increasing the risk of respiratory complications. Despite physician orders, staff failed to monitor and adjust the oxygen settings correctly. Interviews with staff, including an LPN, the Unit Manager, and the DON, confirmed the oversight, with the Unit Manager adjusting the oxygen to the correct level upon discovery.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct complete and thorough investigations into multiple allegations of abuse involving six residents out of a sample of twenty-two. According to the facility's own policy, all alleged violations involving mistreatment, sexually inappropriate behaviors, and abuse or neglect are to be thoroughly investigated, including immediate investigation and interviews with the resident or other witnesses. However, in several cases, such as when a resident called the police alleging theft and inappropriate touching by other residents, and when another resident reported being hit in the chest by a male friend, the facility did not conduct additional resident interviews as required. The Administrator confirmed that these interviews were not performed during the investigations. Further review revealed additional failures to investigate allegations. In one instance, a resident alleged that another resident put a hand around her neck while removing a smoking apron, and although staff intervened and separated the residents, there was no evidence of a comprehensive investigation. In another case, a hospital social worker reported concerns about bruises on a resident's body after a fall, but there was no documentation that this allegation was investigated. The Administrator acknowledged awareness of the report but confirmed that no investigation was conducted. These actions and inactions demonstrate a pattern of incomplete abuse investigations, contrary to facility policy.
Failure to Report Allegation of Physical Abuse to State Survey Agency
Penalty
Summary
The facility failed to notify the State Survey Agency (SSA) of an allegation of physical abuse involving one resident. According to the facility's policy, all employees are required to immediately notify administrative staff and the SSA of any complaint or allegation of resident abuse as soon as the facility becomes aware. In this case, the Director of Nursing (DON) was informed by a hospital Social Worker about concerns regarding bruising observed on a resident's body. The Social Worker communicated that the bruises were noted during the resident's hospital stay, and the DON explained that the resident had previously fallen forward out of his wheelchair due to a tendency to lean forward. Despite being made aware of the bruising and the concern raised by the hospital Social Worker, there was no documentation that the SSA was notified of this allegation of physical abuse. The Administrator confirmed during an interview that the call from the hospital Social Worker was known and acknowledged that the incident was not reported to the SSA as required by facility policy.
Unsanitary Conditions of Garbage Dumpsters
Penalty
Summary
The facility failed to maintain three garbage dumpsters in sanitary conditions, as observed by surveyors. Trash was piled high and spilling over onto the ground, with opened bags exposing dirty briefs with fecal matter and wipes covered in feces scattered around the dumpsters. Swarms of flies were present, and at least 50 large clear white trash bags containing food, trash, and soiled personal care items were observed on the ground. The Dietary Manager and Maintenance Director confirmed the unsanitary conditions and reported that the issue had persisted since the previous Monday due to insufficient space in the dumpsters. The Maintenance Director revealed that the trash was not picked up because the facility had not paid the trash service bill. He informed the Administrator of the issue on 8/13/2024, but no specific instructions were given on how to handle the trash pile-up. The Administrator confirmed the unsanitary conditions and acknowledged the lack of guidance provided to staff. He stated that the corporate office was notified about the payment issue on 8/14/2024 and believed the bill had been paid. The Administrator was unaware of the trash spilling onto the ground and stated he would have addressed it if informed.
Unsafe Water Temperatures and Environmental Hazards in Facility
Penalty
Summary
The facility failed to maintain safe water temperatures in 12 of 28 resident bathrooms and two of three resident shower rooms, as observed by surveyors. The water temperatures in these areas were found to be higher than the recommended levels, with temperatures ranging from 110.3 to 123 degrees Fahrenheit. The Maintenance Director admitted to checking water temperatures daily but acknowledged that the temperatures were not consistently maintained at the recommended levels. The facility's policy on water temperatures was not effectively implemented, leading to potential risks of burns and scalds for residents. Additionally, the facility did not ensure an environment free from chemical and environmental hazards in one of the shower rooms. Observations revealed a cart containing a bottle of 70 percent isopropyl alcohol and a plugged-in hair dryer, along with various items scattered on the floor, creating potential accident hazards. The Administrator and Maintenance Director confirmed these findings and acknowledged the unacceptable condition of the shower room, which posed numerous risks to residents. The facility's failure to adhere to its policies on maintaining safe water temperatures and preventing environmental hazards in resident areas resulted in a deficient practice. The lack of a policy on environmental hazards further contributed to the unsafe conditions observed in the shower room, placing residents at risk of avoidable injuries and a diminished quality of life.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that one of two medication carts was locked and secured when unattended by the nurse, as required by their policy titled 'Medication Administration Guidelines.' This policy, dated August 2021, mandates that medication carts must be kept locked at all times unless under the direct supervision of a licensed nurse. During observations on August 18, 2024, the surveyor noted that Medication Cart 2 was left unattended and unlocked in the hallway on two separate occasions. In the first instance, the cart was left open from 12:15 pm to 12:21 pm until RN JJ approached and locked it. Later that day, at 6:41 pm, the same cart was again found unattended and unlocked until LPN II noticed the surveyor's presence and secured it. Interviews conducted with the nursing staff confirmed the oversight. RN JJ acknowledged that the cart was unlocked during her shift without a nurse present. LPN II admitted to leaving the cart open earlier in the shift, attributing the lapse to being preoccupied with a resident who was transported to the emergency room. Further interviews with the Unit Manager and the Director of Nursing reiterated the expectation that medication carts should always be locked unless a nurse is actively administering medications. The failure to adhere to this policy posed a potential risk of unauthorized access to medications by residents or visitors.
Infection Control Deficiencies in Glucometer Use and Linen Storage
Penalty
Summary
The facility failed to adhere to proper infection control practices during a glucometer check for a resident. An LPN was observed performing a fingerstick blood sugar test without using a barrier on the cart where supplies were placed, both before and after the procedure. This was confirmed by the LPN, the Unit Manager, and the Director of Nursing, who all acknowledged that a barrier should have been used to prevent cross-contamination. Additionally, the facility did not properly store personal care items such as washbasins and urinals in resident restrooms. Observations revealed that these items were unbagged and unlabeled, which was confirmed by the Director of Nursing as not meeting the facility's standards. This lack of proper labeling and storage could lead to cross-contamination among residents. The facility also failed to follow its own policies regarding the storage and handling of linen and biohazardous waste. Observations showed that clean linen was uncovered and exposed, and soiled linen was improperly stored in shower rooms. Furthermore, sharps containers were found to be overfilled, with exposed razors, indicating a failure to manage biohazardous waste correctly. These issues were acknowledged by the facility's staff, including the Administrator and the Infection Control Preventionist, as potential infection control concerns.
Failure to Cover Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R251, by not covering the resident's indwelling urinary catheter drainage bag with a privacy bag. This deficiency was observed on two occasions, where the drainage bag was uncovered and visible as the resident walked down a hallway. The resident was admitted to the facility with a urinary catheter due to urinary retention, as indicated in the care plan, but there were no interventions noted for covering the drainage bag. Interviews with the Director of Nursing, a Certified Nursing Assistant, and the Administrator confirmed that the drainage bag should have been covered for dignity purposes. Additionally, the facility was unable to provide a policy regarding the use of privacy bags for catheter drainage bags.
Unauthorized Medications Found at Residents' Bedsides
Penalty
Summary
The facility failed to ensure that two residents did not have unsecured and unauthorized medications at their bedside, which placed them at risk for inappropriate and unsafe medication use. Resident 49, diagnosed with vascular dementia and other conditions, was found with a prescription albuterol inhaler in his room, despite not being assessed or approved to self-administer medications. The inhaler was obtained from a previous medical appointment, and the resident reported using it occasionally. The Unit Manager confirmed the presence of the inhaler and was unaware of its existence in the room, indicating a lapse in monitoring resident rooms for medications. Resident 1, with severe cognitive impairment and diagnosed with dementia, schizophrenia, and bipolar disorder, was found with a bottle of mouthwash containing alcohol at the bedside. There was no assessment for self-administration of medication for this resident. The Unit Manager confirmed the unauthorized mouthwash, which was not allowed due to its alcohol content, and removed it from the room. The Director of Nursing was unaware of these unauthorized medications and highlighted the potential risks associated with their use, such as increased heart rate and adverse effects on blood pressure.
Failure to Conduct Pre-Employment Screenings
Penalty
Summary
The facility failed to ensure that pre-employment screenings, specifically reference checks and fingerprinting, were conducted prior to employment for four out of ten employees reviewed. This deficiency was identified during a review of employee files, which revealed that a reference check was not completed for a Dietary Supervisor hired in 1998, a Certified Nursing Assistant hired in 2024, and a Dietary staff member hired in 2024. Additionally, an Activities Assistant hired in 2024 did not have a fingerprint procedure completed, despite working multiple shifts without this requirement being fulfilled. The Director of Human Resources acknowledged the missing pre-employment requirements, attributing the oversight to being very busy and not having the opportunity to call references or complete the fingerprinting process within the required timeframe. The Administrator was unaware of the missing pre-employment requirements and did not provide an explanation for the absence of this information in the employee files. This oversight had the potential to place residents at risk of abuse, neglect, and exploitation from staff.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement person-centered comprehensive care plans for three residents, leading to deficiencies in their care. One resident, diagnosed with paranoid schizophrenia, Alzheimer's disease, and vascular dementia, had a care plan that included the use of a fall mat to prevent fall-related injuries. However, observations over several days revealed that the fall mat was not placed by the resident's bedside as required. Interviews with staff, including an LPN and the Regional Director of Nursing, confirmed the absence of the fall mat and highlighted a lack of adherence to the care plan. Two other residents, both with respiratory conditions, had care plans that required specific oxygen settings. One resident with chronic obstructive pulmonary disease was observed receiving oxygen at a higher flow rate than prescribed, and staff were unaware of the care plan's requirements to monitor and adjust the oxygen settings. Similarly, another resident with acute chronic respiratory failure was also receiving oxygen at an incorrect flow rate. Interviews with the Unit Manager and MDS Coordinator revealed a lack of awareness and adherence to the care plans, resulting in the incorrect administration of oxygen.
Failure to Follow Physician Orders for Therapy and G-tube Care
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to deficiencies in their care. For one resident, who was admitted with a diagnosis including contracture of the left hand, there was a physician's order for evaluations for physical therapy, occupational therapy, and speech therapy. However, these evaluations were not conducted, and the resident expressed concern about not receiving therapy services for a splint device and range of motion exercises. The Unit Manager and Director of Rehabilitation confirmed that the order was not followed, and the resident did not receive the necessary therapy evaluations. For another resident with diagnoses including dysphagia and severe protein-calorie malnutrition, the facility failed to document the required gastrostomy tube water flushes as per physician's orders. The orders specified water flushes after each medication and before and after feedings, but there was no documentation of these flushes in the medication administration record or progress notes. An LPN verified that the water flushes were not documented, and the Regional Director of Nursing stated that the nurse responsible for receiving the physician's order should have transcribed it onto the medication administration record.
Failure to Provide ROM Services for Resident with Contracture
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion (ROM) for a resident with a contracture of the left hand. The resident, identified as R43, was admitted with a diagnosis that included contracture of the left hand. Despite having a cognitive status indicating little to no impairment, the resident did not receive physical or occupational therapy as documented in the admission Minimum Data Set. Physician orders for therapy evaluations were issued, but the care plan did not include specific instructions for ROM exercises for the left hand, and the contracture was not noted in the Certified Nursing Assistants' (CNA) Plan of Care. Observations during the survey revealed that the resident was not using a splint device, and the fingers of the left hand were folded into the palm. Interviews with the resident and staff confirmed that ROM exercises were not being provided. The CNA acknowledged awareness of the contracture but did not perform ROM exercises. The Unit Manager and Director of Rehabilitation were aware of the contracture but confirmed that no therapy evaluation had been conducted. The Director of Nursing stated that therapy recommendations are typically added to the CNA Plan of Care after evaluations, which had not occurred in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with physician orders for two residents, R49 and R68, which had the potential to increase the risk of respiratory complications. R49, diagnosed with chronic obstructive pulmonary disease (COPD) with acute exacerbation and hypokalemia, had a physician order for oxygen at 2 liters per minute (LPM) at night and as needed. However, observations revealed that R49 was receiving oxygen at 2.5 LPM instead of the prescribed 2.0 LPM. Similarly, R68, diagnosed with acute chronic respiratory failure with hypoxia and hypercapnia, had a physician order for oxygen at 2 LPM as needed for shortness of breath, but was also observed receiving oxygen at 2.5 LPM. Interviews with staff, including a Licensed Practical Nurse (LPN), the Unit Manager, the MDS Coordinator, and the Director of Nursing (DON), confirmed the discrepancy in oxygen administration. The LPN and Unit Manager were unaware of the incorrect oxygen settings, and the Unit Manager adjusted the oxygen to the correct level upon discovery. The MDS Coordinator noted that R49 had a history of adjusting his oxygen flow meter, and the DON emphasized the expectation for staff to ensure oxygen was administered according to physician orders. The failure to monitor and adjust the oxygen settings as prescribed placed the residents at risk for complications, particularly for R49, who was at risk of COPD exacerbation due to receiving more oxygen than ordered.
Latest citations in Georgia
The facility failed to follow its abuse investigation policy when responding to an allegation that a male resident wandered into a female shared room, allegedly sat on a resident’s bed, inappropriately touched her leg, stared at another resident, and opened the bathroom door to watch a third resident brushing her teeth. The allegation was reported by a cognitively intact resident and involved residents with varying levels of cognitive impairment. The investigation, conducted by the Administrator and former DON, relied only on interviews with a RN and a CNA, did not obtain required written, signed, and dated witness statements, and did not include interviews with other residents to assess their sense of safety. Despite these omissions and incomplete documentation, the facility’s final report concluded the allegation was unsubstantiated.
A resident with protein calorie malnutrition and a terminal prognosis was admitted on hospice with corresponding physician orders and a care plan, but hospice services were not coded on either the admission or quarterly MDS assessments. The MDS Coordinator and two MDS LPNs confirmed that, despite the resident receiving hospice care, Section O of both MDS assessments incorrectly indicated the resident was not on hospice, which the Administrator and DON acknowledged resulted in inaccurate MDS data.
Surveyors found that PTAC unit filters in two resident rooms on one hallway were not maintained free of visible grey, fuzzy debris, despite facility policy requiring regular inspection and cleaning or replacement at least every three months. Across multiple observations on different days, the condition of the dirty filters remained unchanged. The Maintenance Director reported he is responsible for monthly cleaning and checks, including spot checks and inspections in construction areas, and did not dispute the observed dust accumulation when shown. The Administrator confirmed that maintenance staff are responsible for monthly PTAC filter cleaning as part of preventative maintenance and acknowledged that this issue could negatively affect residents’ health and well-being.
A resident with intact cognition and known skin integrity risks reported being left on a bedpan for an extended period and not being adequately cleaned by a CNA. The following shift, another CNA found the resident on soiled linens with a blister on the left upper thigh but did not report this new skin issue to the charge nurse or DON. Subsequent documentation showed development of an open area on the thigh associated with pain, and later NP evaluation identified a larger wound requiring sharp excisional debridement. These events show failure to provide adequate incontinent care and to promptly assess and report a new wound, contrary to the facility’s abuse/neglect prevention policy and CNA responsibilities.
A cognitively intact resident with skin-related diagnoses reported delayed and inadequate incontinent care after using a bedpan, describing prolonged waits for staff response and feeling not properly cleaned by a CNA. The next morning, another CNA found feces-soiled linen and a blister on the resident’s left upper thigh, later documented as a new open area. The resident texted the Administrator stating that a CNA had left feces on her and that she had developed a painful blister, but the Administrator did not report this allegation of neglect to the State Survey Agency as required by facility policy.
A resident with lymphedema and identified risk for pressure ulcers developed a new open wound on the upper thigh, documented by a NP with specific wound measurements. Although the existing care plan included interventions to observe and document skin changes, the care plan was not updated to include this new wound. The Wound Care Nurse and the resident confirmed the wound location, while the MDS Coordinator reported not receiving recent weekly wound reports and only recently learning of the wound. The MDS Coordinator confirmed that the care plan had not been revised in real time as required by facility procedures, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
The facility did not complete a required Georgia Criminal History Check System (GCHEXS) fingerprint background check for a CNA, as identified during review of ten employee files with a census of eighty residents. The facility’s abuse-prevention policy required criminal background checks for all employment candidates, but there was no documentation of a fingerprint records check for this CNA. The HR manager, who is responsible for background and fingerprint checks and maintaining employee files, confirmed that the GCHEXS fingerprint check had not been conducted, resulting in a deficiency under F-Tag 600.
Surveyors found that four of six resident shower rooms were not kept free of hazards or adequately cleaned. On one floor, razors were on the floor, dirty gloves and a comb were on a shower bed, floors were stained, an opened gallon of bath soap and a bottle of chemical-resistant spray were present, and a razor and hair clippers were in a bag on the floor along with a shower cap and toothbrush. On other floors, surveyors observed multiple opened containers of skin and hair cleaner, conditioner, and skin ointment, along with a strong urine odor. Unit managers and the Environmental Senior Director stated that CNAs were responsible for cleaning after each resident and that environmental services cleaned shower rooms daily, and acknowledged that items should not be left on the floor and that product containers should be closed.
Surveyors found that staff did not follow standard and transmission-based precautions when handling ice on two floors. On one floor, the ice scoop cover on top of the ice machine had visible black specks near the end of the scoop used to dispense ice. On another floor, the ice scoop was observed submerged in ice and water inside the cooler used to serve residents, despite the unit manager acknowledging that the scoop should not be left in the cooler. The Maintenance Director reported that maintenance cleaned and checked ice machines regularly, while nursing staff were responsible for cleaning scoops and covers. The SDC/Infection Control nurse stated that all staff had been in-serviced on hand hygiene and ice scoop protocol, including that scoops should be stored in a holder after use and never left in the ice.
A resident with multiple serious conditions, moderate cognitive impairment, and total dependence for ADLs was placed in bed with side rails intended to assist with positioning, despite the MDS indicating no bed rail use. Facility records showed no evidence of safe rail spacing or regular inspection of the bed and rails. The assigned CNA, who came on duty late in the evening, last saw the resident around the start of the shift and did not check on him again for several hours, relying on the resident to use a call light. In the early morning, the CNA and an RN found the resident partially out of bed, entrapped in the half side rail, requiring multiple staff to free and reposition him. The resident was unresponsive except for moaning, with altered mental status and respiratory failure documented by EMS and the ER, and later expired at the hospital. The facility’s failure to provide required monitoring and to ensure safe side rail use resulted in neglect and Immediate Jeopardy.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an allegation of sexual abuse in accordance with its policy titled “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating.” The policy required that all allegations be thoroughly investigated, including reviewing documentation and evidence, interviewing any witnesses, interviewing staff on all shifts who had contact with the resident, and completely documenting the investigation, with written, signed, and dated witness statements. A facility-reported incident documented that a male resident was wandering into a female three-bed room, allegedly inappropriately touching one resident, staring at another for a length of time, and then opening the bathroom door and staring at a third female resident while she was brushing her teeth. The allegation was initially reported by a cognitively intact resident (BIMS score 15) and involved another resident with moderate cognitive impairment (BIMS score 8) and a resident with severe cognitive impairment (BIMS score 99). The Administrator reported that the investigation of this incident was conducted by the former DON and herself after the allegation was reported by a RN. She stated that this was not the first time the alleged male resident had wandered into other residents’ rooms and described the allegation as the male resident entering a resident’s room, sitting on the resident’s bed, and allegedly touching the resident’s leg. Staff interviews for the investigation were limited to the RN and a CNA, and the Administrator acknowledged that no written witness statements were obtained, contrary to facility policy. She also confirmed that no additional residents were interviewed to assess their sense of safety following the incident. The facility’s final investigation report concluded that the allegation was unsubstantiated, despite the lack of comprehensive interviews, written statements, and full documentation required by the facility’s abuse investigation policy.
Failure to Accurately Code Hospice Services on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for a resident receiving hospice services. The facility’s policy on Certification of Accuracy of the MDS requires that appropriate health professionals correctly document residents’ medical, functional, and psychosocial problems using the Resident Assessment Instrument. The resident in question was admitted with diagnoses including protein calorie malnutrition and had a care plan dated 01/09/2026 indicating a terminal prognosis and admission to hospice, with a goal to honor advance directives and provide comfort with dignity. Physician’s orders dated 12/09/2025 also included an order to admit the resident to hospice. Despite this, review of the admission MDS and a subsequent quarterly MDS showed that hospice services were not coded in Section O (Special Treatments, Procedures and Programs), even though both assessments documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. Interviews with the MDS Coordinator and two MDS LPNs confirmed that the resident had been on hospice since admission and that both the admission and quarterly MDS assessments were incorrectly coded as not on hospice. The MDS Coordinator acknowledged that the MDS should present an accurate clinical picture for a given period and stated that this was a clerical error, resulting in CMS not receiving correct hospice coding for the resident. The Administrator and DON stated their expectation that MDS assessments accurately reflect residents’ services and confirmed that failure to code hospice in the MDS results in an inaccurate reflection of the data.
Failure to Maintain Clean PTAC Unit Filters in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain Packaged Terminal Air Conditioner (PTAC) unit filters in a safe, clean condition in two resident rooms on the Sapphire Hallway. The facility’s written policy titled "Instructions" requires that air filters be removed and inspected for cleanliness, washed or replaced if dirty, and at a minimum replaced or thoroughly cleaned every three months. During multiple observations in one room on 3/22/2026, 3/24/2026, and 3/25/2026, the PTAC unit filter was noted to have visible grey, fuzzy debris accumulation, with no change in condition across all three observations. Similar repeated observations on those same dates in another room showed the PTAC unit filter also contained visible grey, fuzzy debris accumulation that remained unchanged. In an interview, the Maintenance Director stated he is responsible for cleaning and checking the PTAC filters monthly, including conducting monthly checks and random inspections in areas where construction is occurring, and confirmed that the maintenance department is responsible for ensuring filters are clean and functioning properly. He also stated that expectations include spot checks of PTAC units. However, during an observation of one of the affected rooms in his presence, dust accumulation was again observed on the PTAC unit filter, and he did not dispute the finding. In a separate interview, the Administrator stated that the maintenance department is responsible for cleaning PTAC filters, which are supposed to be cleaned monthly, and that her expectation is for preventative maintenance to be completed monthly and as needed, noting that a potential negative outcome is the impact on residents’ health and well-being.
Neglect of Incontinent Care and Delayed Wound Reporting Leading to Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to prevent neglect and to assess and provide timely wound and incontinent care to a cognitively intact resident with known skin integrity risks. The resident, who had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema, was care planned as being at risk for pressure ulcer development and skin integrity issues, with interventions directing staff to observe, document, and report any changes in skin status. On a night shift, the resident reported being left on a bedpan for approximately an hour and a half. When the CNA on that shift (CNA BB) assisted with post-toileting care, the resident told her she did not feel adequately cleaned; CNA BB did not recheck or further clean the resident and left the room. The next morning, the resident reported burning in the left upper thigh and informed another CNA (CNA EE) that she had not been cleaned well. During morning care, CNA EE found the pad under the resident soiled with feces and wet with urine and observed a blister on the resident’s left upper thigh, but did not report the new blister to the charge nurse or DON. A subsequent Skin Wound Note documented a new open area on the left posterior thigh with the resident reporting pain while sitting on the bedpan. Later, an NP wound care consult documented that the thigh wound had been present for approximately two weeks per nursing report and measured 3.5 cm x 4.0 cm x 0.2 cm, requiring sharp excisional debridement to remove necrotic tissue and decrease bacterial burden. On observation by the surveyor with the Wound Care Nurse, the left upper thigh area was open to air, shiny pink and granular, about the size of a half dollar. These findings demonstrate that the facility did not follow its abuse/neglect prevention policy and CNA job responsibilities to provide necessary care and to report changes in condition, resulting in neglect of incontinent care and delayed wound assessment and treatment for this resident.
Failure to Report Allegation of Neglect to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the State Survey Agency (SSA) as required by its own abuse and neglect reporting policy. The facility’s policy, dated 1/2025, states that any complaint, allegation, observation, or suspicion of resident neglect must be immediately communicated to the Abuse Coordinator and promptly investigated and documented, and that all alleged violations involving mistreatment, abuse, or neglect will be thoroughly investigated under the direction of the Administrator in accordance with state and federal law. Despite this, the Administrator acknowledged that an allegation of neglect reported by a resident was not reported to the SSA. The resident involved was cognitively intact, with a BIMS score of 15, and had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. The resident reported that during a night shift she requested assistance for incontinent care after using a bedpan and experienced multiple delays before a CNA assisted her. She stated that when the CNA finally provided care, she did not feel adequately cleaned, and the CNA did not verify cleanliness before leaving. The next morning, another CNA found soiled linen with feces and a blister on the resident’s left upper thigh, which the resident reported as burning. A subsequent skin/wound note documented a new open area on the left posterior thigh. The resident texted the Administrator describing that a CNA had left feces on her and that she had developed a painful blister. The Administrator confirmed receiving this text but did not report the allegation of neglect to the SSA, despite being aware it should have been reported.
Failure to Update and Implement Care Plan for Newly Developed Pressure Ulcer
Penalty
Summary
Surveyors identified a failure to implement and update the care plan for a newly developed pressure ulcer for one resident. The facility’s policy "RAI Care Planning Management" requires a comprehensive, accurate assessment and real-time modification of the care plan when changes occur. The resident was admitted with diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. A recent MDS quarterly assessment showed the resident was cognitively intact (BIMS 15), at risk for pressure ulcer development, and had no unhealed pressure ulcers at that time. The existing care plan, dated 6/6/2024, identified potential for pressure ulcer development and skin integrity issues related to immobility and lymphedema, with interventions to observe, document, and report changes in skin status, including wound size, stage, and signs of infection. Subsequently, a NP wound report documented a new open wound on the resident’s thigh that had been present for approximately two weeks, with specific measurements recorded. During observation and interview, the Wound Care Nurse and the resident confirmed the wound was on the left upper thigh, which differed from the NP report that referenced the right thigh. The MDS Coordinator reported she previously received weekly wound sheets from the Wound Care Nurse but had not received one in about a month, and that the DON was now responsible for emailing the weekly wound report. She verified that the last wound report she received did not include this resident and stated that new wounds should be discussed in the morning management meeting and the care plan updated in real time. The MDS Coordinator confirmed she only recently became aware of the upper left thigh wound and that the resident’s care plan had not been updated to reflect this new wound, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
Failure to Complete Required GCHEXS Fingerprint Check for CNA
Penalty
Summary
The facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for one CNA among ten employee files reviewed, despite a census of eighty residents and a written policy requiring criminal background checks for all employment candidates. The policy titled "Freedom of Abuse Abuse Prevention Fast Alert" dated 1/2025 states that, as part of pre-employment screening, all candidates must authorize a criminal background check for conviction of crimes. During record review with the Human Resources Manager (HRM), there was no documentation of a fingerprint records check for CNA BB, and the HRM confirmed that this CNA did not have a GCHEXS fingerprint check conducted. The HRM also stated that she is responsible for background checks, fingerprint checks, reference checks, and maintaining employee files. This failure to complete the required fingerprint background check for CNA BB resulted in noncompliance cited under F-Tag 600. No resident-specific medical histories, conditions, or direct resident care events were described in the report related to this deficiency.
Failure to Maintain Safe and Clean Conditions in Multiple Resident Shower Rooms
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate environmental controls in multiple resident shower rooms. On the 4th floor, observation with the Unit Manager showed four razors on the floor, dirty gloves and a dirty comb on a shower bed, stained/dirty floors, an opened gallon bottle of complete bath soap, and a bottle of chemical resistant spray in the shower room. A razor and hair clippers were found in a black bag on the floor, and a shower cap and toothbrush were lying on the floor. The 4th floor Unit Manager stated that CNAs were supposed to clean up before showering residents and acknowledged that the items found should not be on the floor. The Environmental Senior Director reported that shower rooms were cleaned daily, with responsibilities including cleaning high-touch areas, sweeping and mopping floors, removing linen, and cleaning the area, and stated there had been no complaints about showers not being cleaned. On the 3rd floor, observation with the Unit Manager revealed an open bottle of skin and hair cleaner, an open bottle of conditioner, and an open bottle of skin ointment in the resident shower room. The 3rd floor Unit Manager stated that items in the shower room should be closed and that CNAs were to clean after each resident. On the 2nd floor, observation with the Unit Manager revealed two opened gallon containers of skin and hair cleaner and a strong urine odor in the shower room. The 2nd floor Unit Manager stated that the soap should have a top on it and that CNAs were responsible for cleaning after each resident. These observations and interviews showed that four of six resident shower rooms were not maintained free of hazards and were not cleaned as expected by facility staff, creating the potential for injury and spread of infection as stated in the report.
Improper Ice Scoop Handling and Storage Breaches Infection Control Protocol
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper handling and storage of ice scoops on two of four floors. On the 4th floor, observation of the ice scoop and scoop cover showed black specks near the end of the scoop used to put ice in cups, and the scoop cover was located on top of the ice machine. The 4th floor Unit Manager stated that kitchen staff cleaned the scoops once a week and acknowledged that the scoop should be clean. On the 3rd floor, observation of the ice chest/cooler used to serve residents revealed the ice scoop submerged in ice and water. The 3rd floor Unit Manager later confirmed that the ice scoop was not supposed to be left in the cooler. The Maintenance Director reported that maintenance staff were responsible for cleaning the ice machines, which were checked weekly and monthly, while nursing staff were responsible for cleaning the ice scoops and covers. The Staff Development Coordinator/Infection Control staff stated that all staff had been trained in infection control procedures, including hand hygiene and handling of the ice scoop and holder, and that staff had been educated that the ice scoop should be placed in the scoop holder after use and never left in the ice. Documentation in the maintenance logbook showed monthly checks and cleaning of all four ice machines, and the ice machine cleaning log showed that the ice machines on the 2nd, 3rd, and 4th floors and in the kitchen had been cleaned on specific dates. Staff training records indicated that an in-service on handwashing and ice scoop protocol had been provided for all staff.
Neglect Related to Inadequate Supervision and Unsafe Side Rail Use Leading to Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to inadequate supervision and oversight of side rail use, resulting in entrapment. Facility policies on Abuse, Neglect and Exploitation required protections to prevent neglect, defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy on Proper Use of Bed Rails required a person-centered approach, attempts at alternatives before bed rail use, and ensuring correct installation, use, and maintenance of bed rails, including attention to entrapment risk. For this resident, the Medicare 5-day MDS indicated moderate cognitive impairment (BIMS score of 8), total dependence on staff for all ADLs, and documented that bed rails were not used, while an admission assessment documented side rails were placed to assist with movement in bed. Facility records showed no evidence that safe rail spacing and regular inspection of side rails and beds had been completed. The resident had multiple serious medical diagnoses, including acute and subacute infective endocarditis, end stage renal disease, hemiplegia and hemiparesis following cerebral infarction, bacteremia, and cervical disc degeneration, and was dependent on staff for all ADLs. Nursing staff last observed the resident at 12:46 am when a sponge bath was provided; there was no documented monitoring or ADL assistance between 12:46 am and 4:30 am. The assigned CNA reported coming on duty at 11:00 pm, seeing the resident up with the bed in a low position, placing the call light in the resident’s hands, and not seeing or checking the resident again until approximately 4:30–5:00 am, stating that the resident did not press the call light during that time. Around 5:00 am, the CNA requested help from the RN, reporting that the resident needed assistance. The RN found the resident with the lower part of his body hanging off the bed and the upper body still on the bed, with his elbow wedged into the half side rail, requiring three staff to reposition him back into bed. The RN stated the resident, who was quadriplegic, was no longer as alert as when put to bed, did not respond to sternal rubs, had open but unfocused eyes, and was not verbally interactive. The CNA described finding the resident on his knees, all the way out of bed, with one hand tangled in the side rail, and noted that he was moaning but not talking after being returned to bed. Progress notes documented that EMS was called for evaluation and treatment due to the resident’s condition, and hospital ER records indicated he arrived with altered mental status and respiratory failure, agonal respirations, and a GCS of 3. The facility’s Maintenance Director stated bedrails had been checked the prior year but could not provide proof, and requested documentation of safe rail spacing and regular inspection was not provided.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
